Accident Investigation - European Aviation Safety Agency · Temporary revision of the FCOM SOP 4 Safety Recommendations related to design ... Dash 8 accidents review. 17-Apr-07 Accident

17-Apr-07 Accident Investigation 2007 report Bernard Bourdon

Accident Investigation

Annual update17 April 2008

17-Apr-07 Accident Investigation 2007 report Slide2

European Aviation Safety Agency

Interface with AIBs in 2007 -Generalities

Interface is improvingECAC interfaceDebriefing on investigations

Good interaction on the phoneAccess to data/meetings more difficult due to

National regulationsImplications of a draft publication outside the scope of an investigationLack of trustNo defined status

ReportingLanguage issuesADREP usageDocument format shall help the identification of SR



Management of Investigations, the need

Initial notificationECCAIRS format for data exchange and storage

Participation to investigationsSafety Recommendations

Factual data should be made available to a level that enable a clear and unambiguous understanding of the recommended actionSharing of the follow up given to recommendations


2007 activity



Investigation activity 2007

A320 PR-MBK 17.07.2007 Sao PauloPrevious events and questionsClarifications to ANAC and the CENIPA AD, ASR, critical analysis of the design

Simulator evaluation by the Flight PanelTemporary revision of the FCOM SOP4 Safety Recommendations related to designNo report issued



•DHC8-402Q, LN-RDK Aalborg 09-09-2007•DHC8-402Q, LN-RDI Copenhagen 27-10-2007

DHC8-400, LN-RDSVilnius 11-09-2007

DHC8-400, D-ADHAMunich 22-09-2007

Metallurgical examination made in Denmark

TC + Bombardier

13-09-2007 EAD 2007-0252

16-10-2007 AD 2007-0272



Implemented actions12-09-2007 SAS Fleet grounded and CoA revoked13-09-2007 EAD 2007-025220-09-2007 flight ban lifted gradually as each plane is inspected. 04-10-2007, 90% of the Bombardier fleet back into service16-10-2007 AD 2007-0272 superseding EAD 2007-025227-10-2007 SAS Fleet grounded, CoA dismissed

Dash 8 accidents review



Investigation tasks

Factual dataMetallurgical examination of Aalborg and Vilnius events made in a Danish laboratoryAFM emergency procedures review

PublicationsLN-RDK preliminary report on 25.09.2007 (Danish AIB)LN-RDS preliminary report on 04-10-2007 (Lithuanian AIB)LN-RDI preliminary report on 29.10.2007 (Danish AIB)LN-RDI interim report on 30.10.2007 (Danish AIB)LN-RDI interim report on 03.11.2007 (Danish AIB)



Investigation activity 2007

DHC6 F-OIQI 09.08.2007 Moorea9 oct. 2007 Urgent Safety recommendation published6 Dec. 2007 preliminary reportSR, airworthiness coordination (18/12) and, fleet survey (20/01), maintenance manual review



EASA development

Flight Data AnalysisRead out and validation done by the AIBExploitation and reporting for internal useVisualization for various EASA experts not on siteConfidentiality is a key factor



Reporting: Origin of data

ICAOADREP

Countries’Investigation and

Safety Recommendations

EASASafety database

ADREP data comes to EASA

But data also comes from Countries.

Or is obtained from other sources …



Improving Eccairs reporting

Eccairs is the central system to search for occurrences and provide statistics

Extended search capabilitiesBetter handling of language issues

Attachment of reports available in Eccairs databaseThe database will be connected to the future SR databaseGet the benefit of all incoming reports

Coding of Eccairs occurrences subcontracted to an external company



ECCAIRSDatabase

(JRC central repository)

SafetyRecommendations

Database

Two separate systems linked by a n:n relation

Safety analysisThematic search by• Descriptive factor• Explanatory factor• Text search / field

NotificationUpdatesReports

Process & reply toSafety Recommendations


Safety Initiatives perspectives


European Aviation Safety AgencyIn line with with the ICAO Global Aviation Safety Roadmap



COORDINATION GROUP

ECASTEUROPEAN

COMMERCIAL AVIATION SAFETY

TEAM

EHESTEUROPEAN

HELICOPTER SAFETY TEAM

EGASTEUROPEAN

GENERAL AVIATIONSAFETY TEAM

International Partners

International Partners

WORKING GROUPS

WORKING GROUPS International

Partners

WORKING GROUPS



Phase 1. Identify and Select Safety Priorities

Phase 2. Analyse Safety Issues

Phase 3. Develop, Implement, and Monitor

Actions Plans

COORDINATION

Programme Reviews – 2012 and 2017

COMMUNICATION

ECAST has Developed a new Three Phase Process



ECAST Work Priorities Areas

18. Automation

17. Maintenance (HF)

16. Airworthiness (Maintenance & Design)

15. Air Navigation

14. Loss of Control (Weight & Balance)

13. Bird Strike

12. Icing

11. CFIT

10. Mid Air Collision

9. Air-Ground Communications

8. Fire, Smoke and Fumes

7. Aviation System Complexity

6. Approach & Landing

5. Loss of Control (General)

4. Flight Crew Performance

3. SMS & Safety Culture Selected2. Runway Safety

1. Ground Safety Selected



ECAST Phase 2 (Started 2008)

ECAST has set up a Working Group on Safety Management Systems, closely cooperating with EASA RulemakingWG on Ground Safety will be launched in the 2nd part of 2008



Conclusion

The conduct of investigations is the sole responsibility of Member StatesInvestigations data are required, due to EASA’s responsibilitiesCurrent situation

Good will from technical investigatorsInterface with the industry

Objective: secure an agreement allowing the qualified people to share available facts and act upon

Documents

Accident Investigation - European Aviation Safety Agency · Temporary revision of the FCOM SOP 4 Safety Recommendations related to design ... Dash 8 accidents review. 17-Apr-07 Accident